Saturday, 27 July 2013

A Fortunate Occurrence

It used to be typical that AF would announce herself with a few warning light pink spots that I would notice only if were meticulously inspecting the toilet tissue. I never counted this as the first day of my cycle as I figured that no normal woman is staring at the toilet tissue, so it becomes a little like the proverbial tree that falls in the forest -if no one hears it, does it make a sound? I judged it to be a courtesy, much akin to flashing your headlights to on-coming traffic to alert other drivers of a speed trap ahead. As my cycles are very light, this is what I define as "spotting" When it's to the point of needing a liner, that's my full flow. However, on my past two cycles, AF has skipped the preliminary rounds and has launched right into her version of full flow. Nonetheless, I observed for a few hours before emailing my RE's office to report that my cycle was starting. A bit convenient too, as I would be out of the office for an all-day inservice training on my CD2, so I wouldn't have to cancel any patients. I asked for a late morning or early afternoon appointment, which would fit in with the lunch break. The office manager responded that they could see me at noon, but she added "if it's not quite at full flow, it may be best to wait until Friday." While on one hand I was impressed that she actually remembered details from my records, it also seems weird that she knows the intimate aspects of my cycle so well.

While performing my scan, my RE noted that my endometrium seemed pretty thick and he asked the office manager (who was filling in as a chaperone) what cycle day this was. "Well, her spotting started yesterday..." she reported. As I was listening to two other people discuss when my period began, I thought I'd offer that I was needing a tampon by mid-day and I nearly soaked a medium absorbency tampon overnight -that's practically hemorrhaging for me. This was a legitimate day 2. "Well, I think you'll still have a bit more heavier bleeding" he forecasted (he was wrong). Still mulling over whether or not this was CD1 or CD2, he decided to have me take my Femara on CD3-7 rather that the usual CD2-6. For the second time in my life, it felt like no one believed me about when I started my period.

He asked me to return on the next Friday at CD9/10. As I've learned the hard way, that if you don't ask, you don't get; I thought I'd try to use the dispute over my cycle start to my advantage. "So, if we were to call this CD1, does that mean I could schedule my next appointment on a Saturday?" I asked a la Monty Hall in 'Let's Make a Deal'. He replied that the office isn't always open on Saturday -it depends if any IVF patients need monitoring. Thus confirming an earlier suspicion that IVF patients are granted higher priority. Not that it isn't warranted, I just appreciated someone being upfront about it. I can empathise with what it must be like to work every Saturday. Even though it's only a few hours in the morning, it locks you into a routine. However, you knew this going into this field... He also empathised with how difficult it is for me to leave my office and my patients and agreed to see me at noon again.

This would be manageable. I had a new OB visit scheduled at 11:00 on that Friday. I figured I could see her earlier in the week, but leave her on the schedule -thus giving me access to leave the office seemingly unnoticed.  I always try to reschedule patients to an earlier date as a measure of good customer service. I figure if you're able to come in sooner, you may not mind the inconvenience of being re-scheduled. However, some patients requested a particular day or time as it fits their schedule. This was one of those situations. The patient had started a new job and could only come in on Fridays. "Squeeze her in for tomorrow at 8:40" I instructed to my medical assistant. Really...? her eyes asked. "You know she is a new patient" she reminded me of my preference not to start a new session with a brand new patient, (As she may have trouble finding the office and arrive late and then need to register and complete her paperwork, and I'm running behind before I even walk in the room) "It will be fine." I replied to her in my 'just do what I ask' voice.

They were a sweet couple. Recently moved to the area and didn't get around to making an appointment with a woman's health provider to renew her prescription for birth control pills, so they decided to "see what happens." It is the same process to call to schedule a new OB visit as it is to get an appointment for pills.. I thought to myself. The giggled with each other over their amazement at how quickly they conceived. Seems to be a recurring theme... After all, she had heard [the rumours] that it can take months to become fertile again after using the pill and he noted that it took his brother and his wife "nearly a year" to conceive his nephew. I did my bit to educate about fertility before moving on to her exam.

By dates she should have been nine weeks. As she was thin, I was able to perform a good bimanual exam. Her uterus felt normal size. Fuck. She likely had an early pregnancy failure. As I set her up for her ultrasound, I rehearsed my miscarriage pronouncement in my mind. Then things went from bad to worse. Her scan revealed a thickened endometrium with no evidence of an intrauterine pregnancy and there was some thing suspicious looking in her right adnexa. Double Fuck. She had an ectopic pregnancy.

I sent her for a formal scan and an hour later I received a call from the radiologist with her prognosis. 3.5 cm right ectopic, small amount of fluid present to suggest hemorrhage. She was not eligible for methotrexate. She would need a laparoscopy and would likely lose her tube. This couple walked into the office thinking that they were winners in the fertility sweepstakes. Not only did I feel as if I were taking away their giant check, I was imposing a penalty of compromised fertility potential.  Oh, but first we had to address this life threatening situation at hand. I called my colleague who was on-call at the hospital. "Pre-op her in the office, I'll call the OR" she arranged. The couple were in a bit of shock, but willingly agreed to proceed with her surgery. Naturally, she asked the question for which I had no answer; "Why did this happen?" There were no risk factors in her history. "We're just so glad we came in today." her husband reflected.

I quietly sighed to myself. It was a fortunate occurrence. If nothing else comes out of our fertility project, I will always know that there is someone out there who benefited from my infertility. Still it was hard to swallow. At our last encounter, my RE reminded me that I had a legitimate medical issue and encouraged me not to feel guilty about seeking treatment for myself. I think almost every health care professional finds that it is instinctive to place the needs of those you care for above your own. Additionally, my procedures are technically elective. As satisfied as I was that things had worked out for the best, I felt haunted by the alternate endings. What if she couldn't have come in earlier? I know I can't shoulder all these burdens, but again it's hard when I know how overworked and overwhelmed my colleagues are. It all just give me more fodder to resent the situation of infertility. I hate the fact that others are also inconvenienced by my infertility.

My colleague returned to the office at the end of the day. She reported that she had to remove her tube, but the patient did well and would be going home tomorrow morning. "Good catch, Jane" she complimented "If I hadn't operated on her today, I'd be operating on her over the weekend."
"I rescheduled her." I confessed "I brought her in early to accommodate my own selfish needs for my fertility monitoring appointments."
She just smiled and placed her hand on my shoulder. "Jane, there is such a thing as simply being in the right place at the right time."


  1. Wow, what an amazing story. Reading your blog has truly made me rethink my view of the medical industry, kind of similar to the way that becoming a teacher radically changed my view of education. "If I don't want to be here teaching/grading/conferencing today, it's likely that my own professors probably felt the same about me at times..." Also, if I have to somewhat arbitrarily assign a grade for those hard to categorize in-between students at times, well, I'm not the only one. It really did rip away my naiveté about education as a polished "system"--like everything, in the end it all comes down to flawed human beings and the various ways they handle the little bit of power given to them.

    Reading your blog has made me really think more about my doctors and their staff as people, with their own lives and their own problems. As always, thank you for sharing this story. I found it fascinating.

    I also felt a little bit guilty because as I was reading, I silently cursed the "lucky" couple and their bliss. But then as I finished the rest of the story, I was reminded that sometimes even those who appear to be lucky really aren't. Nothing is guaranteed for any of us.

    I'm glad to hear your period flow has been a little heavier! Fingers crossed for your scan next week!

  2. Great story. I too was about to curse the couple for getting pregnant so easily. The problem is--you never hear these stories discussed openly, only happy endings. I also feel that I can look at the medical community from a different perspective now. Is your increased flow a sign of progress? (Aren't you glad we're close enough that I can ask about your flow?)

  3. I'm thankful for you, too, Jane! And even if that hadn't ended up to be a pregnant woman with an ectopic pregnancy that needed catching, you shouldn't feel guilty about rescheduling patients because of fertility related needs. What kind of doctor would you become if you didn't first care for yourself? I am good at what I do, in part, because I pay close attention to caring for myself. I'd be a far less effective clinician if I didn't!

  4. Wow. This story is a great reminder on not too judge too quickly. I'm so sad for that couple. Walking in to what you think is just your first first OB appointment and getting that. It's sobering.

    I always get confused about what is day one for me, too. Ugh. It's the weird bleeding that you aren't sure if you should count it as spotting, or CD1.

  5. I am always amazed at how much my RE works. For my first IVF cycle, I saw her on July 4th (Thursday), Saturday, and Sunday. I don't know how I should feel about her family of three little children but she is just such a dedicated professional. And you are too. I am happy that you were there for the couple when needed. Your colleague is right. You were there at the right time.

  6. well I am sorry that you had one of those "another reason to hate infertility" moments. they suck. you are smart for realizing that you cannot carry all of these burdens all of the time! Self awareness if the first step!

  7. It's always interesting to read things from the health care provider's perspective. To be honest, sometimes it's easy to forget that my OBGYN is a woman just like me, and may be going through her own emotional issues. I am always so focused on myself when I see her I never stop to think what she might be thinking...

    I'm so sorry for that couple though. I hope she is still able to get pregnant someday down the road.

  8. I love the closing line of your post. "right place at the right time". In theory...isn't that also what this infertility "game" is about. One sperm and the write place at the write time.

  9. I have always had a super light flow as well, with a day or two of spotting before hand. It's easy to tell the difference btw spotting and what is considered "full flow" though. That was probably frustrating that the RE didn't believe you. I am so sad for that couple that came in to see you. So excited when they came in, only to leave needing surgery and w/o a tube, which may make getting pregnant a second time much more difficult. I sometimes have to juggle my clients as well. While it is difficult and may be sometimes frustrating for the patient, you shouldn't feel guilty for scheduling around your needs as well. I wish all health care providers put as much into their jobs as you do.